napronaprotehnologija tehnologija –zamjena za ivf? zamjena ... 12.05.2012/002 napro ujevic zadar...
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NaProNaPro tehnologija tehnologija –– zamjena za IVF? zamjena za IVF?
Boris Boris UjevićUjević
Tanja Tanja TurudićTurudić
Osnove Osnove NaProNaPro tehnologijetehnologije
� 50 godina prošlog stoljeća dr. John Billings je “otkrio” cervikalnu sluz (sluz vrata maternice)
� tijekom menstrualnog ciklusa nastupaju promjene u vrsti i količini sluzi
ona se još zove "plodna sluz" jer je nužno potrebna da � ona se još zove "plodna sluz" jer je nužno potrebna da bi došlo do trudnoće
� žena zato, ako primjećuje sluz, zna da je u "plodnim danima" i da može zatrudnjeti, a ako sluzi nema, zna da ne može zatrudnjeti, jer je bez nje začeće nemoguće
Osnove Osnove NaProNaPro tehnologijetehnologije
� cervikalna sluz se luči pod utjecajem spolnih hormona
� cervikalna sluz je savršen instrument za mjerenje plodnosti, ali ne samo plodnosti već i svakog odstupanja od normalnog stanja koji može biti rezultat od normalnog stanja koji može biti rezultat hormonalnog poremećaja ili nekog oboljenja
� NaPro tehnologija se temelji na praćenju cervikalne sluzi i bilježenjem svih promjena u vaginalnom iscjetku
Osnove NaPro tehnologijeOsnove NaPro tehnologije� prate se promjene na stidnici prilikom
uobičajenih svakodnevnih aktivnosti � ne istražuje se unutrašnjost rodnice� standardizacija u promatranju i bilježenju -
objektivni klinički znakovi objektivni klinički znakovi
Osnove Osnove NaProNaPro tehnologijetehnologije
� “Fertility care system” je praćenje i bilježenje ženskog ciklusa putem standardizirane tablice (kalendara)(kalendara)
� u tablicu se stavi obojena markica i simbol� upiše se kratak opis osjeta na stidnici i izgleda
sluzi
NaProNaPro tehnologijatehnologija
� NaPro tehnologija - medicinski i kirurški pristup liječenju ženskog zdravlja i plodnosti na temelju “Fertility care system”
� Abnormalnosti zabilježene u tablici su samo vrh patofiziološkog ledenog brijega!
su povezane s:• hipotalamičko – hipofiznom disfunkcijom
• slabom funkcijom folikula
• poremećanim nivoima estrogena i
Abnormalnosti u tabliciAbnormalnosti u tablici
• poremećanim nivoima estrogena i progesterona
• PCO
• endometriozom
Infertility & Miscarriage
Low Endorphins
Diet &Nutrition
Surgical
Male Factor
Low Hormones
Limited Mucus
Infection
Nutrition
Immunological
AdrenalFatigue
OthersTo be discovered
NaProNaPro tehnologijatehnologija
u skladu s općeprihvaćenim medicinskim principima
• anamneza
• simptomi
• klinički status• klinički status
• pretrage
• dijagnoza
• konzervativna i/ili kirurška terapija
FertilityFertilityCareCare tablica =tablica =klinikliniččkiki statusstatus
� suhi ciklusi
� smanjena količina sluzi
� premenstrual spotting
intermenstrual spotting� intermenstrual spotting
� smeñe krvarenje na kraju menstruacije
� kratka lutealna faza
� duga lutelna faza
� dugi ciklusi
PretragePretrageCiljano ispitivanje hormonaCiljano ispitivanje hormona
• Peak Plus 7Progesteron (18.5 - 31.0 ng/dl) (60 - 100 nmol/L) Estrogen (145 – 300 pg/l) (400 – 800 nmol/l)Estrogen (145 – 300 pg/l) (400 – 800 nmol/l)
• Peak Plus 3,5,7,9,11
• Pre Peak P-3, P-1, P+1 • Estrogen - preko 370 pg/l (1000 nmol/l)
PretragePretrageUltraUltrazvukzvuk• folikulometrija
• mali folikuli
• inkompletna ruptura• inkompletna ruptura
• Luteinised Unruptured Follicle
• uredna ruptura
• endometralni odgovor
DijagnozaFUNKCIONALNI poremećaj
• deficit hormona - folikularni ili lutealni
• poremećena ovulacija
– anovulacija
– sindrom luteiniziranog nerupturiranog folikula– sindrom luteiniziranog nerupturiranog folikula
– parcijalna ruptura folikula
• limitirani protok cervikalne sluzi – upale
• muški faktor
STRUKTURNI poremećaj
• endometrioza, miomi, polipi, septum
Possible Diagnoses from NaProTechnology Evaluation
Hormonal Ultrasound Surgical Other
Low Progesterone Immature follicle Endometriosis Limited (hostile)
Mucus
Low Oestradiol Partial rupture Pelvic Adhesions Adrenal Fatigue
Poor Follicular
Function
Luteinised unruptured
follicle
Blocked Fallopian
Tubes
Chronic Endometritis
Corpus Luteum Delayed Rupture Hydrosalpinx*
Corpus Luteum
Insufficiency
Delayed Rupture HydrosalpinxEndorphin Deficiency *
Polycystic Ovaries Afollicularism Fibroid Food Intolerance
Reduced ovarian
reserve
Absent Cumulus
Oopherous
Polyp Nutritional Deficiency
Hypothyroidism Uterine Septum Immune dysfunction
*Although these diagnoses are hormonally mediated, at least in part, the diagnosis and management is not based on direct hormonal testing at this time.
Liječenje
FUNKCIONALNO • Podrška lutealnoj fazi - HCG, Progesteron• Pojačanje sluzi -Vitamin B6, Mukolitici, Antibiotici• Indukcija ovulacije Clomiphene, HCG, FSH, GnRH• Imunološki - food intolerance• Imunološki - food intolerance• Adrenal fatigue - Kortikosteroidi• Niski endorfini - Naltrexon• Stres Management
STRUKTURALNO - kirurško
Bolest može biti …….Bolest može biti …….
Akutna
� nagli početak
� kratko trajanje
Kronična
� postupan početak
� duže trajanje� kratko trajanje
� može proći spontano
� najčešće jedan uzrok
� može se izliječiti s jednim zahvatom i/ili lijekom
� duže trajanje
� rijetko prolazi spontano
� najčešće više uzroka
� ishod liječenja se poboljšava dugotrajnom primjenom više lijekova i/ili zahvata
KroničanKroničan vs Avs Akutni pristupkutni pristup
NaPro Tehnologija� traži dugotrajne
zdravstvene tegobe i pokušava ih poboljšati
MPO� dugotrajne zdravstvene
tegobe smatra manje važnim od kratkotrajnog pokušava ih poboljšati
kroz cijeli reproduktivni život
� kronična perspektiva
važnim od kratkotrajnog liječenja
� akutna perspektiva
Kroničan Kroničan vsvs AAkutni pristupkutni pristup
NaPro Tehnologija
� neplodnost predstavlja prisustvo bolesti, koju
MPO
� neplodnost predstavlja tehnički izazov da se prisustvo bolesti, koju
treba otkriti i liječititehnički izazov da se premosti nefunkcionalni proces
Neplodnost je kronično stanjeNeplodnost je kronično stanje
Neplodnost je najčešće posljedica više kroničnih stanja (rijetko akutne bolesti)
(Ne)logično je kronično stanje liječiti akutnim (Ne)logično je kronično stanje liječiti akutnim zahvatom
Case ACase A
�� GravidaGravida 0 Para 0, 0 Para 0, �� Female aged 41, Male aged 40, Female aged 41, Male aged 40, �� Trying to conceive for 2 yearsTrying to conceive for 2 years
Case ACase A
�� Unexplained InfertilityUnexplained Infertility◦◦ Lap and Dye Lap and Dye –– normal 2007normal 2007
◦◦ Semen analysis Semen analysis –– normal 2007normal 2007
�� IUI x 3 IUI x 3 –– FSH/LH and HCG FSH/LH and HCG -- June 2008June 2008�� IUI x 3 IUI x 3 –– FSH/LH and HCG FSH/LH and HCG -- June 2008June 2008�� IVF x 2 IVF x 2 ◦◦ 3 Embryos transferred 3 Embryos transferred –– Aug 2008 & March 2009Aug 2008 & March 2009
�� Presented for Presented for NaPro NaPro treatment treatment –– March 2009March 2009
Case A Case A –– NPT DiagnosesNPT Diagnoses
�� Chronic EndometritisChronic Endometritis�� Progesterone deficiency Progesterone deficiency ◦◦ poor follicular function poor follicular function
◦◦ & corpus luteum insufficiency& corpus luteum insufficiency◦◦ & corpus luteum insufficiency& corpus luteum insufficiency
�� Hostile Cervical MucusHostile Cervical Mucus�� Clinical endorphin deficiencyClinical endorphin deficiency�� Mild food intoleranceMild food intolerance
Case A Case A –– NPT TreatmentsNPT Treatments
�� Clinical endorphin deficiencyClinical endorphin deficiency◦◦ Naltrexone 2mg Naltrexone 2mg noctenocte
�� Mild food intolerance (Mild food intolerance (IgGIgG) ) ◦◦ Egg yolk and soyaEgg yolk and soya◦◦ Egg yolk and soyaEgg yolk and soya
Case A Case A –– NPT treatmentNPT treatment
�� Progesterone deficiency Progesterone deficiency ◦◦ poor follicular function poor follicular function
◦◦ & corpus luteum insufficiency& corpus luteum insufficiency
�� Letrozole 2.5mg 10 tabs on day 3Letrozole 2.5mg 10 tabs on day 3�� Letrozole 2.5mg 10 tabs on day 3Letrozole 2.5mg 10 tabs on day 3�� HCG 10,000 iu mid cycle HCG 10,000 iu mid cycle �� HCG 2,500 iu Peak +3,5,7HCG 2,500 iu Peak +3,5,7
Case A Case A –– NPT TreatmentsNPT Treatments
�� Hostile Cervical MucusHostile Cervical Mucus◦◦ CaCarbrbocistocisteeine 375mg tid x 7 days, day 11ine 375mg tid x 7 days, day 11
◦◦ Amoxycillin 500mg tid x 5 days, day 11Amoxycillin 500mg tid x 5 days, day 11
◦◦ PreSeed Vaginal LubricantPreSeed Vaginal Lubricant◦◦ PreSeed Vaginal LubricantPreSeed Vaginal Lubricant
Case A Case A –– NPT TreatmentsNPT Treatments
�� Chronic Chronic EndometritisEndometritis◦◦ Metronidazole 400mg BD x 3 weeksMetronidazole 400mg BD x 3 weeks
◦◦ Clarithromycin 500mg BD x 3 weeksClarithromycin 500mg BD x 3 weeks
◦◦ Pro biotic for 6 weeksPro biotic for 6 weeks◦◦ Pro biotic for 6 weeksPro biotic for 6 weeks
Start day 14 of cycleStart day 14 of cycle
Case ACase A
�� 42 years old at conception 42 years old at conception �� Hormone support with Hormone support with cyclogestcyclogest 400mg 400mg pvpv. .
twice daily until 8 weeks twice daily until 8 weeks �� CyclogestCyclogest 400mg 400mg pvpv noctenocte until until 116 weeks 6 weeks �� CyclogestCyclogest 400mg 400mg pvpv noctenocte until until 116 weeks 6 weeks
gestationgestation
Case ACase A
�� She delivered a healthy baby boy by Caesarean She delivered a healthy baby boy by Caesarean section in November 2010, weighing 3180g.section in November 2010, weighing 3180g.
Case ACase A
�� Chart was critically important to the processChart was critically important to the process◦◦ Timing of blood testsTiming of blood tests
◦◦ Timing of HCG injectionsTiming of HCG injections
◦◦ Identify hostile mucusIdentify hostile mucus◦◦ Identify hostile mucusIdentify hostile mucus
◦◦ Identify Brown Bleed Identify Brown Bleed –– Chronic Chronic EndometritisEndometritis
Case ACase A
IVF which attempted to solve the symptom of IVF which attempted to solve the symptom of infertility through bypassing the natural process infertility through bypassing the natural process of conception was inappropriate and ineffective of conception was inappropriate and ineffective as she had several chronic conditions that as she had several chronic conditions that as she had several chronic conditions that as she had several chronic conditions that needed to be treated in a targeted fashion to needed to be treated in a targeted fashion to restore normal reproductive functionrestore normal reproductive function
Case BCase B
�� GravidaGravida 1 Para 0 1 Para 0 �� Female aged 37 Male aged 39 Female aged 37 Male aged 39 �� 7 years trying to conceive 7 years trying to conceive
Case BCase B
�� Trying to conceive since Jan 2002Trying to conceive since Jan 2002�� Cycle 32 to 25 daysCycle 32 to 25 days�� Unplanned miscarriage at 11 weeks Unplanned miscarriage at 11 weeks –– 19991999�� Diagnosis Diagnosis –– Mild PCOD by ultrasoundMild PCOD by ultrasound�� Diagnosis Diagnosis –– Mild PCOD by ultrasoundMild PCOD by ultrasound
Case B Case B –– UsualUsual investigationsinvestigations
�� Laparoscopy ’01 &’08, Laparoscopy ’01 &’08, �� Hysteroscopy ‘09Hysteroscopy ‘09�� Semen analysis several tests Semen analysis several tests –– ’01’01-- ’08’08�� Day 3 bloodsDay 3 bloods�� Day 3 bloodsDay 3 bloods�� ThrombophilliaThrombophillia ScreenScreen�� Immunological testing “Chicago Bloods”Immunological testing “Chicago Bloods”
Case B Case B –– TreatmentsTreatments
�� Clomiphene Clomiphene ◦◦ 50mg daily for 5 days, from day 3 of cycle x 450mg daily for 5 days, from day 3 of cycle x 4
◦◦ 100mg daily for 5 days, from day 3 of cycle x 4100mg daily for 5 days, from day 3 of cycle x 4
◦◦ 150mg daily for 5 days, from day 3 of cycle x 4150mg daily for 5 days, from day 3 of cycle x 4◦◦ 150mg daily for 5 days, from day 3 of cycle x 4150mg daily for 5 days, from day 3 of cycle x 4
�� 12 cycles in total previously12 cycles in total previously
Case B Case B –– TreatmentsTreatments
�� IVF x 3 stimulated cycles IVF x 3 stimulated cycles ◦◦ Feb 2006 Feb 2006 –– March 2009March 2009
◦◦ Embryo transfer Embryo transfer –– 3 fresh and 1 frozen3 fresh and 1 frozen�� 2 2 –– 3 embryos each time3 embryos each time2 2 –– 3 embryos each time3 embryos each time
�� Additional Aspirin, Enoxaparin, Prednisolone 25mg with last Additional Aspirin, Enoxaparin, Prednisolone 25mg with last IVF cycle despite normal testingIVF cycle despite normal testing
Case B Case B –– NPT DiagnosesNPT Diagnoses
�� Presented Presented for NaPro treatment for NaPro treatment on April 2009on April 2009�� Progesterone deficiency Progesterone deficiency –– with corpus luteum with corpus luteum
insufficiencyinsufficiency�� Polycystic Ovaries Polycystic Ovaries –– with poor follicular with poor follicular �� Polycystic Ovaries Polycystic Ovaries –– with poor follicular with poor follicular
functionfunction�� Clinical endorphin deficiencyClinical endorphin deficiency�� Clinical Adrenal fatigueClinical Adrenal fatigue
Case B Case B –– NPT TreatmentsNPT Treatments
�� Progesterone deficiency Progesterone deficiency –– with corpus luteum with corpus luteum insufficiencyinsufficiency
�� Polycystic Ovaries Polycystic Ovaries –– with poor follicular with poor follicular functionfunctionfunctionfunction◦◦ HCG 2,500iu P+3,5,7,9HCG 2,500iu P+3,5,7,9
◦◦ Letrozole 2.5mg Letrozole 2.5mg –– 16 tabs 16 tabs –– day 3day 3
◦◦ HCG 10,000 iu mid cycleHCG 10,000 iu mid cycle
Case B Case B –– NPT TreatmentsNPT Treatments
�� Clinical endorphin deficiencyClinical endorphin deficiency◦◦ Naltrexone 3mg nocteNaltrexone 3mg nocte
�� Clinical Adrenal fatigueClinical Adrenal fatigue◦◦ Hydrocortisone 5mg Hydrocortisone 5mg –– 7am & 12 noon7am & 12 noon◦◦ Hydrocortisone 5mg Hydrocortisone 5mg –– 7am & 12 noon7am & 12 noon
�� SupplementsSupplements◦◦ Vitamin D3 Vitamin D3 –– 2,400iu daily2,400iu daily
◦◦ Omega 3 2000mg daily plus Folic acidOmega 3 2000mg daily plus Folic acid
Case B Case B –– NPT OutcomeNPT Outcome
�� With treatment we achieved a normal With treatment we achieved a normal appearing chart, with proven follicle rupture appearing chart, with proven follicle rupture by ultrasound, and a healthy happy patient. by ultrasound, and a healthy happy patient.
�� She conceived on her 5th cycle of treatment She conceived on her 5th cycle of treatment �� She conceived on her 5th cycle of treatment She conceived on her 5th cycle of treatment (second effective cycle) in April 2010(second effective cycle) in April 2010
Case B Case B –– NPT Pregnancy treatmentNPT Pregnancy treatment
�� Cyclogest 400mg pv twice daily until 36 Cyclogest 400mg pv twice daily until 36 weeks gestationweeks gestation
�� Aspirin 75mg daily until 30 weeks Aspirin 75mg daily until 30 weeks �� Aspirin 75mg daily until 30 weeks Aspirin 75mg daily until 30 weeks �� Prednisolone 25mg daily until 12 weeks Prednisolone 25mg daily until 12 weeks
Case B Case B –– NPT Pregnancy OutcomeNPT Pregnancy Outcome
�� She had a normal vaginal delivery of a healthy She had a normal vaginal delivery of a healthy baby boy, 3.130 Kg in January 2011baby boy, 3.130 Kg in January 2011
�� Mother was 38 years old at deliveryMother was 38 years old at delivery�� Mother was 38 years old at deliveryMother was 38 years old at delivery
Case B Case B –– CommentsComments
�� Immediately identified Corpus luteum Immediately identified Corpus luteum insufficiency & confirmed restoration of insufficiency & confirmed restoration of normal function with treatment.normal function with treatment.
�� Patient’s well being improved with naltrexone Patient’s well being improved with naltrexone �� Patient’s well being improved with naltrexone Patient’s well being improved with naltrexone and cortisol treatment. When this happens, we and cortisol treatment. When this happens, we often find our treatment is more successful. often find our treatment is more successful.
Case CCase C
�� GravidaGravida 1 (with IVF), Para 01 (with IVF), Para 0�� Female age 38, Male age 38Female age 38, Male age 38�� Never conceived naturally since trying in Never conceived naturally since trying in
February February 20032003February February 20032003�� OligoasthenozoospermiaOligoasthenozoospermia and endometriosis and endometriosis
Case C Case C –– Previous TreatmentsPrevious Treatments
�� 12 cycles of ovulation induction with 12 cycles of ovulation induction with clomipheneclomiphene
�� 3 attempts at IUI 3 attempts at IUI �� 3 failed IVF attempts between Dec 2005 and 3 failed IVF attempts between Dec 2005 and �� 3 failed IVF attempts between Dec 2005 and 3 failed IVF attempts between Dec 2005 and
April 2007April 2007◦◦ 2 embryos replaced x 3 IVF cycles2 embryos replaced x 3 IVF cycles
◦◦ Miscarriage at 9 weeks after first attemptMiscarriage at 9 weeks after first attempt
Case C Case C –– NPT DiagnosesNPT Diagnoses
�� Presented Presented for for NaProNaPro tretmenttretment in January in January 20082008
�� EndometriosisEndometriosis�� OligoasthenozoospermiaOligoasthenozoospermia�� OligoasthenozoospermiaOligoasthenozoospermia�� Clinical endorphin deficiencyClinical endorphin deficiency�� Low progesterone and Low progesterone and oestradioloestradiol –– combined combined
poor follicle function and corpus poor follicle function and corpus luteumluteuminsufficiency insufficiency Obvious from ChartObvious from Chart
�� Food Intolerance to eggsFood Intolerance to eggs
Case C Case C –– NPT TreatmentsNPT Treatments
�� Clinical endorphin deficiencyClinical endorphin deficiency◦◦ Naltrexone 4.5mg nightlyNaltrexone 4.5mg nightly
�� Food Intolerance to eggsFood Intolerance to eggs�� Food Intolerance to eggsFood Intolerance to eggs◦◦ Change in dietChange in diet
Case C Case C –– NPT TreatmentsNPT Treatments
�� EndometriosisEndometriosis◦◦ Laparoscopy and diathermy June 2008Laparoscopy and diathermy June 2008
�� OligoasthenozoospermiaOligoasthenozoospermia◦◦ CoEnzyme Q10 200CoEnzyme Q10 200 mg dailymg daily◦◦ CoEnzyme Q10 200CoEnzyme Q10 200 mg dailymg daily
◦◦ Tamoxifen 20Tamoxifen 20 mg dailymg daily
◦◦ FertilityPlus for menFertilityPlus for men
◦◦ Lifestyle Lifestyle –– (cigarettes, alcohol, caffeine, stress)(cigarettes, alcohol, caffeine, stress)
Case C Case C –– NPT TreatmentsNPT Treatments
�� Low progesterone and Low progesterone and oestradioloestradiol –– combined combined poor follicle function and corpus poor follicle function and corpus luteumluteuminsufficiencyinsufficiency◦◦ Clomiphene 150mg daily x 3 days, starting on day Clomiphene 150mg daily x 3 days, starting on day ◦◦ Clomiphene 150mg daily x 3 days, starting on day Clomiphene 150mg daily x 3 days, starting on day
3 of the cycle with HCG 5000 3 of the cycle with HCG 5000 iuiu mid cycle to mid cycle to facilitate follicle rupture and HCG 2,500 facilitate follicle rupture and HCG 2,500 iuiu on on days 3, 5 and 7 after ovulation days 3, 5 and 7 after ovulation
Case C Case C –– NPT Pregnancy TreatmentsNPT Pregnancy Treatments
�� Positive pregnancy test in September 2008 Positive pregnancy test in September 2008 �� Cyclogest 400mg pv nocte until 14 weeks Cyclogest 400mg pv nocte until 14 weeks �� Naltrexone 4.5mg nocte until 38 weeksNaltrexone 4.5mg nocte until 38 weeks
Case C Case C –– NPT Pregnancy outcomeNPT Pregnancy outcome
�� They had a healthy baby boy by normal vaginal They had a healthy baby boy by normal vaginal delivery weighing 3.400kg in June 2009, when delivery weighing 3.400kg in June 2009, when mum was 40 years old.mum was 40 years old.
Case C Case C –– repeat attemptrepeat attempt
�� Second attempt in February 2010 Second attempt in February 2010 �� Same treatment approach successfully Same treatment approach successfully
conceived by September 2010. conceived by September 2010.
�� Healthy baby boy delivered 19th May 2011 Healthy baby boy delivered 19th May 2011 when mum was 42 years old.when mum was 42 years old.
Case C Case C –– CommentsComments
�� CChart demonstrated premenstrual spotting hart demonstrated premenstrual spotting indicating a problem with endometrial indicating a problem with endometrial integrity in the luteal phase of the cycleintegrity in the luteal phase of the cycle
�� It is important to adequately treat mild It is important to adequately treat mild �� It is important to adequately treat mild It is important to adequately treat mild endometriosis as this has been shown to endometriosis as this has been shown to improve pregnancy and live birth ratesimprove pregnancy and live birth rates
Primjer 1
� G0, P 0� Dob Ž: 28 � Dob M: 33 � Trudnoću pokušavaju 4 godine � Trudnoću pokušavaju 4 godine � U program se uključili: 06/2009
Primjer 1
� Astenoteratozoospermia, + Prouteus Mirabilis (2 godine, terapija antibioticima bezuspješna)
� Željeli inseminaciju no - dvije hrvatske vodeće klinike isključivo ICSIklinike isključivo ICSI
Primjer 1
� NaPro terapija:� Prestati pušiti, smanjiti količine alkohola i kave,
smanjiti stres, vježbati� Multivitamini (FertilityPlus for men)� Multivitamini (FertilityPlus for men)� Coenzim Q 10� Ciprofloxacin 250 mg bid -2 x dnevno, 6 tjedana
- uspješno eliminirali bakteriju Proteus Mirabilis� LDN
Primjer 1
� M: 9 mjeseci terapije – trudnoća� Bligted ovum u 8 tj. trudnoće – kiretirana
(10/2009)� Ž: nije imala terapiju jer još nije počela voditi � Ž: nije imala terapiju jer još nije počela voditi
kalendar
Primjer 1
� Ž:� Poor Follicular Function� Clomid 50mg daily for 3 days, start day 3 of
cycle.� Utrogestan 200mg pv nocte x 10 nights, start
Peak +3 of cycle.� Supplements -Vitamin D3 2,400 daily, Omega 3
2000mg daily, folic acid� Avoid milk and eggs
Primjer 2
� G0, P0� Dob Ž: 34g� Dob M: 38g� Trudnoću pokušavaju 4g� Trudnoću pokušavaju 4g� U program se uključili: 06/2009
Primjer 2
� NaPro� insuficijencija žutog tijela� sumnja na polip i endometriozu� muški faktor� muški faktor
Primjer 2
� HYS - odstranjen polip� LPSC - endometrioza pelvičnog peritoneuma� LPSC - obostrana neprohodnost jajovoda
Primjer 2
� Terapija:� M: ciprofloksacin 2x250mg, 3 tjedna� Ž:� Klomifen 50mg 3 dana od 3.d.c.� Klomifen 50mg 3 dana od 3.d.c.� HCG 10000 i.j. P-1, 2500i.j. P+3,5,7� LDN 3mg� prehrana: izbjegavati mlijeko i mliječne
proizvode, jaja
Primjer 3Primjer 3
� Vesna Vulović je pala iz aviona s 10 000 metara i preživjela
� Većina koja padne s 10 000 metara će preživjeti?preživjeti?
Usporedba Usporedba NaProNaPro i i MPOMPO
� Nizozemska MPO
� N=1351
� Starost žene=32.8g
� Irska NaPro
� N=1072
� Starost žene =35.8g
� Trajanje neplodnosti=3.6g
� Prethodni MPO=0%
� 1 godina◦ 64.7% trudnoća
� Trajanje neplodnosti=5.6g
� Prethodni MPO=33%
� 2 godine ◦ 52.8% poroda
Hum Reprod 2007JABFM 2008
ZaključakZaključak
Neplodnost je kronično stanje i kao takvo treba biti liječeno.
Dijagnostički postupci moraju tragati za Dijagnostički postupci moraju tragati za SVIM uzrocima i doprinosnim čimbenicima.
Liječiti treba SVE uzroke i doprinosne čimbenike.
Želja je imati zdravo dijete, majku i oca.
Za koga nije NaPro
� Azoospermija� Neprohodni jajovodi (nakon kirurške
rekonstrukcije)� Postmenopauza� Postmenopauza
NaPro zamjena za IVF?
Za sve one parove koji iz bilo kojeg Za sve one parove koji iz bilo kojeg razloga ne žele MPO
Dokazi Dokazi -- Cochrane Cochrane bazabaza
� Outcomes should be reported as pregnancy rates per woman or couple, because repeat cycle data are not because repeat cycle data are not statistically independent and are less relevant to the patient
Pandian et al. Cochrane Database Sys Rev 2005
Cochrane evaluation of IVFCochrane evaluation of IVF
� “The effectiveness of IVF relative to other treatment options for unexplained infertility remains unproven. Adverse events and the costs associated with the Adverse events and the costs associated with the interventions compared have not been adequately assessed.”
Pandian et al. Cochrane Database Sys Rev 2005
Cumulative pregnancy ratesCumulative pregnancy rates
In couples without clear indications for IVF, the main
benefit of early IVF may be to shorten time to
pregnancy, a benefit that must be weighed against
Stanford JB, et al. Fertil Steril 2010
pregnancy, a benefit that must be weighed against
costs and potential adverse outcomes.